How to Get Your Wound Clinic Through an Audit

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Brian McCurdy:
Welcome back to Today's Wound Clinic podcast, where we bring you the latest practical treatment and reimbursement information from leaders in the wound care field. I'm Brian McCurdy, the managing editor of TWC, and with me are Dr. Helen Gelly and Dr. Caroline Fife. Today we're talking about the dreaded audit. You may not be able to avoid an audit, but you can prepare and make it easier on yourself when it happens. Welcome, doctors. Why don't each of you briefly introduce yourselves to the audience?

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
I'm Caroline Fife. I'm the clinical editor for Today's Wound Clinic, and I am Helen Gelly’s biggest fan. So I'm here because I wanna know what Helen has to teach us.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
And I'm Helen Gelly. I practice hyperbaric medicine and wound care in the greater Atlanta area and predominantly in the office setting.

Brian McCurdy:
Okay. So what are the types of audits you've been involved in and what did you do to respond to those audits?

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
It's a whole alphabet soup, isn't it, Helen?

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Yes. The thing to remember about audits is that there are a wide range of audits, and these wide ranging audits have different implications. For example, there is something the government requires both commercial plans and Medicare advantage plans and Medicare plans to audit charts for compliance. And that's called HEDIS audit. This has no direct implications on payment, but they will ask you to send an entire year's worth of clinical records, and they usually ask for about 20 charts per year. This is an audit that is required by the government from these commercial carriers for whatever product they're actually offering, whether it be Medicare Advantage or the commercial plans. And they just get it, they audit it, and then you never hear back to find out what the result was because they are reporting to the government. But if you don't respond, and the paperwork that's involved is huge, especially with some of our patients, as Caroline will attest. I mean, they're annuity patients. We see them every week, sometimes for months, perhaps even the whole year. And you have to print the entire chart and send it. So it becomes a huge administrative burden. However, if you don't comply, it's a potential reason to terminate your contract with that particular insurer. So that, that's one that doesn't have any direct financial implications.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
But it's a huge time suck.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
But it is a huge time—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Suck. Yeah, and I just looked this up. I'm sure people listening probably know what HEDIS means, but I had to look it up. It's the healthcare effectiveness and data information set. And most people have probably heard that term in relation to nursing homes or other types of agencies. It's not something that most of us would've bumped into as a physician.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
But unfortunately, clearly—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
It can happen.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
It clearly it's happening. And predominantly in the wound arena, not as much in the hyperbaric arena from the ones that we've been receiving.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Helen, do you think it, you know, one of the things you commented is we've got, we've all got this percentage of patients that wounds are a chronic illness for them, where even if we heal one another, one's gonna come back. 'Cause they're related to their underlying horrible medical conditions, whether it's scleroderma or vascular disease, DI diabetes, whatever it is. And so this idea that we're gonna heal them and send them on their way is nonsense, but we pretend that those people don't exist. Do you think that makes any difference? Do you think that that's part of our problem because they keep wondering why we have such long periods of time that we're seeing these patients? Or do you think that's a different kind of battle, a different kind of problem?

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
I think it's a different kind of battle because sometimes these are patients that we see that have had an accident, uh, where the treatment, uh, parameters in terms of time are very limited. So it doesn't seem to have any direct—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
We're not being audited because we've seen somebody for a year. I guess that's the thing that I would say.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
But they always ask for an entire year's worth of data, and they want the entire chart. So medical, legally, the entire chart includes all of the other outside documentation as well. So it really becomes an administrative group. Wow. Yeah. Wow.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
That's just one.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
That's just one. The more common one that everyone has been talking about, especially in the hyperbaric community, is targeted probe and educate. So these are based within the regional max, the Medicare contractors. And depending on what state you're in, you may you'll have a different contractor. But the G0277 code, which was predominantly in the hospital outpatient department, uh, was a target for the last two or three—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Years. Explain what that code is, how long?

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
So G0277 is the 30 minute increment for hyperbaric oxygen therapy, which is in the office-based setting, the technical component. And in the hospital outpatient department, it is also the technical component, but it is the part that is historically charged by the hospital, on a UBO4 form. A different type of insurance form. It's not usually connected to the physician supervision charge, which is 99183.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
And which is only billed once in a, in a session, whereas the, the hyperbaric service is in increments of 30 minutes. So it gets billed several times. First—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Yes. Between four and five times historically. Yeah. And you, it would behoove people to look to see what the process is. But sort of in a, in a nutshell, they ask for 40 charts, they audit them for appropriateness, and then they educate you on where your deficiencies are. Then they're expecting you to correct those deficiencies. So they give you perhaps six to eight weeks, perhaps a little bit longer. And then they ask for another 40 charts, and then they apply the same standards, and then they tell you what your error rate was. And this goes on for three different cycles. At the end of the third cycle, if you haven't, quote unquote passed. And the pass rate or the acceptable error rate varies according to each, um, different, uh, contractor. But let's just say it's between 15 and 20% error rate. So if you're higher than that, then you could get referred for, um,

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
A rack audit.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Rack audit, or back to the, you know, the contractor will ask for their money back. All of these things, of course, have terrible consequences because obviously the money has already been spent. Uh, but the worst part of this is that they can actually refer you for something called extrapolation, which means that they say your error rate is 40%, therefore we want 40% of every charge that you've submitted over the past three years, for example. And so, despite the fact that your error rate may vary from diagnosis to diagnosis and from year to year and provider to provider, they have the ability to just do an average and just recoup losses for three years, whether or not it would be valid.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
So, you know, just yesterday, attorney, um, Knicole Emanuel, who I'm, I follow her blog closely because she's Medicare Medicaid lawyer. Just yesterday she posted on her blog that there had been a lawsuit around the extrapolation. And that I, and I don't know how sweeping this determination was, but a judge had ruled that if the error rate was less than 50%, they couldn't extrapolate. And so I don't know I enough law to, uh, or the circumstances to know how big of an impact that's gonna have. But I just wanted to point that out. That just happened because some doc had been told that they were gonna owe back millions of dollars for some, you know, 20% error rate and they had heavily extrapolated and then gone back in time. And it was a very unfair situation. But it raises another thing that I've seen, which I think is really dangerous about the TPE.

When you say 40 charts, that doesn't mean 40 patients, they can ask for 40 hyperbaric encounters on the same patient. Like the, that's the thing that I think is really scary. It's supposed to be a statistical sample, but here's just a possible scenario. You forget to put the hemoglobin A1c in a patient's chart who's getting hyperbarics for a foot ulcer. If they call for 40 different notes from that patient, it's gonna be missing 40 times. So that may be the only patient out of your whole year. You forgot to get the hemoglobin A1c in the chart. So you'll have a hundred percent error rate for that. It's a very sneaky way to look at what's supposed to be a statistical sample. And there doesn't seem to be a recourse about that. That would be an interesting thing to ask somebody like Knicole Emanuel's, like that's not a sample that's statistically relevant, but it's happening. Yes. I dunno that anybody's paid back money because of that, but that is one of the things they do. They will not necessarily look at 40 patients.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Right? That is correct. And again, I've been on a number of these educational calls, and I have to say that they don't feel that they need to be educated despite the fact that, uh, most of the reviewers have no hyperbaric experience.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
It is a one-way education.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
It’s a one-way education. So that's what's happening most, most commonly. But, Caroline, as you know, we received something called an SMRC audit, a supplemental Medicare Review contractor audit, which is currently being administrated by Meridian. The last time there was an SMRC audit for hyperbaric oxygen therapy was in 2014, and the error rate was about 56%. Unfortunately, no information was available from that audit that was publicly available. So we had no idea what we were looking at when we started receiving these, uh, requests for medical records. But if you look on the Meridian website under the SMRC tab, they do have hyperbaric oxygen for lower extremity diabetic wounds for medical review. That is one of their target probes.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
So I just had to look that up too. It's the supplemental medical review contractor. Correct. So these are coming from the Medicare max, the regional, like Meridian or No. Or whatever. Right.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
This is a contracted service that Meridian provides that is completely separate from their other contractor duties. And any contractor can request Meridian to do this review.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
And I think that's another important thing that's kinda like the rack, these smirk audits, the topics are chosen by Medicare, by CMS. That's

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Correct.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
So that it's, it's not chance that Hyperbarics is being audited. They decided to audit that. Just like we've had a rack audit going on for Hyperbarics, they, you know, you're not paranoid if they really are after you, they really are very specifically picking on hyperbaric services and cellular products. We don't wanna, you know, overlook the fact that that's going that's rampant right now and Right. And so, but they're very specifically deciding to do that with these tools.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
That's correct. And uh, one of the other ones is podiatry. And they put podiatry just in general terms, and if you drill down, it has to do with, uh, callous debridement and nail nail trimming services. But I think that they're looking, there are quite a few probes that are actually, have some wound related language that they're looking at. So again, they ask for 40 claims and they want,

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
They pick the claims. They don't just say, Hey, send us 40.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
No, no, they don't. One—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
On these people.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
They tell you which person. Some patients had only one date of service, some patients had six days of service. They were apparently fairly random. They want the entire chart that is associated with that day of service, which that you have to print out the consultation, all the external documents from their referring physician, any x-rays, MRIs, wound cultures, infectious disease consults, A1c and nutritional assessments, vascular assessments, documentation of known, for example, um, radiation, if the patient is a cancer patient,

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Which is a lot of fun if they got their radiation 30 years ago.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Correct.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Which can happen.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
But, but also every single date of service had a different reference number, which means that, oh no, every single one had to have all of that same documentation copied, even if the claims were sequential, because the reference number was different. And there's no way to know whether or not

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
The same auditor is going to be looking, same—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
—Auditors.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Gonna look at, yeah. Oh, that's terrifying. I mean, it, did you just figure that out or was it, is it somehow obvious? I just, I'm not sure that if I got that letter, I would understand that different reference numbers may mean different people or different entities are auditing. I, I don't know that I would've been smart enough to say, oh, let's copy the whole thing over again. Did you learn that the hard way or are you just—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Smarter? Well, well, if you remember in 2015 when G0277, which is the 30 minute hyperbaric treatment code, became part of the physician fee schedule, because we were in the office based setting and it was a new code. We were getting a hundred percent prepayment audit and a—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Yet another tool that we haven't even talked about the prepayment.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Anyway, but anyway, but, but of course, so the average hyperbaric patient gets four treatment, four segments, yeah. For one treatment. And they would ask for, each segment would have a different number. So for every date of service, we had to send all the documentation four times.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
So, and you can't send it electronically. You have to print out all of this and mail it.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Well, they, they claim that you can send it electronically. However, when we tried to sign up for the electronic portal, no one ever sent us back the correct password and login to get in. So technically you can send it electronically.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
And of course the problem with electronic is you don't have the confidence that they got it all. And you don't know. I mean—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Well, but, but mailing it, for example, we were mailing them certified return receipt and they would get lost. So we would have to call them after a week to make sure that they received them and that they were uploaded into their system because we received cards back saying they got them, but then somehow they hadn't gotten uploaded. Oh my gosh. So you really have to have very strict guidelines as to how you send it and then following up to make sure that they received it, and then to make sure that it was uploaded.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
You know, many years ago I went to visit our, I'm sorry to cut you off, Helen. Many years ago I went to visit our Novitas Mac Medical Director for a, you know, I thought, okay, I'll try to preempt some things. This was a long time ago when I was young and, and naive and still had hopefulness. And I go to the office, which is in the Dallas area, you know, I'm in Houston, and they're leading me through these maze of offices to get to her office. And I was walking past and boxes and boxes that looked like they had medical records in them. It felt like that scene from Indiana Jones where they're storing the ark, and I, I can't, you know, confirm that those were boxes of records, but they're the kinds of boxes you send records in. And they were just stacked up to the ceiling in some places. And I thought that was a decade ago. Oh my gosh. How could they possibly keep track of all this? It's terrifying.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Absolutely. Absolutely. So the things that they were looking for, which I think is very important that you actually read what they're asking for is that since they were focusing on diabetic foot ulcers, we have to be able to document 30 days of prior treatment, a vascular assessment, diabetic control, nutritional evaluation and enhancement and moist healing with, uh, progress every 30 days. So the problem was we sent all that documentation, but again, this is partly our problem. I think Caroline, when we had, and you were there when they, um, accepted diabetic foot ulcer patients as an approved indication for hyperbaric oxygen therapy, the concept of a moist wound healing environment, an adequate debridement is very appropriate for a Wagner 3—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
But maybe not for a 4 when you have to necrosis. Yeah, correct.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Yeah. And so when they're saying you did not do moist wound healing, and therefore we are denying the claim, we're saying that it's, it's been rejected when that is the standard of care, you are not expected to debride—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
—Or keep moist an area of, or keep—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
—Moist an area.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Yeah. Right. Yeah. Wow. What do you think? I mean, I don't know that we can, honestly, I feel like it's rigged to fail, so I don't know that any response is gonna help. But, you know, there are some things that we might do, like try to get some guidelines together or some statements from wound care organizations just to say, look, the appropriate standard of care for a necrotic area is not the same debridement. But I mean, do you think that would make any difference?

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
It might. All I know is that they have been very picky in, for example, they wanted evidence of nutritional enhancement because a patient had a low total protein and albumin, which that's another conversation.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Renal—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
—Disease, and they're on dialysis.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Yeah. Yeah.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
They will never have a normal total protein and albumin or they—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
—Get a protein restriction. So you're not supposed to, they'll tell you don't supplement them with protein. And then what are you supposed to do—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
That is correct.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Terrifying that they, and then they hold you accountable. That's just, like I said, it's a, it feels like it's rigg.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
So the other thing that they were asking about was a vascular assessment. And despite the fact that we document the presence or absence of pulses, it didn't appear that that was sufficient. They actually want a number. So people who are doing vascular assessments, who feel abounding pulse, who feel that it is a waste of time and money to send the patients for a segmental doppler evaluation of their arterial system, they need to do that.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Well, of course I decided I would do skin perfusion pressure in my clinic and I'm, you know, I don't work for any of those companies, but it, I thought revolution was my practice, but I couldn't charge for it. 'Cause I don't employ a vascular tech. So trying to convince the hospital that I have to do this in order to make sure that I'm being efficient and meeting all the requirements. But we're gonna give these away because, I don't employ the right kind of people and couldn't is, uh, you know, you probably could in your office 'cause you would've purchased the equipment. But in the hospital based setting, when the hospital purchased the equipment, there has to be a vascular tech that, like, there's a lot of subtlety in there that's just very difficult and frustrating. But I think the point is important that physical exam is not gonna cut it.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Right. And it's unfortunate because a physical exam should cut it. But, that having been said, you know, we sent in the documentation they asked for evidence of a hard sighted chamber. I think that—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
What is evidence of it? It just didn't know. Well, I—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
—Took a picture.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
So I mean, seriously, the fact that you say you treated them in a hard sided chamber wasn't sufficient. You really did have to say, I don't, this is my chamber. It's not inflatable. That's, that's—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
I don't, I don't know the answer to that because I didn't want to test it. So yeah, I just sent a picture of, of the center so that they could see that this in fact did exist.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
I don't you think we have, have start putting the serial numbers of our chambers or something on 'em? I don't know.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Have no idea. I have no idea. But anyway, um, so we sent in the 40 claims, 20 of them were excluded, so half of them were excluded, which were all radiation then. What—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Do you mean excluded?

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
They, I don't know, that's what they said. Excluded. They just, they didn't say anything. They just said excluded and they don't explain what excluded—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
—Is. Oh, you know what? I bet, I bet that means that in the instructions they have for auditing, they're just looking at dpu.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Correct. But we don't know that 100%.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Yeah. Yeah. Yeah.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
So then does that

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Mean they have to come back and ask for more charts? So they have their statistical sample or it doesn't, they they did their job?

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
I don't know. We'll find out. So of the 20 that were left, 14 were found to be approved and six were denied. They were rejected. Of the six that were rejected, one of them was a diabetic foot ulcer patient who had a compromised flap. And so the coating was that it was a flap failure because it had, was a transmitted tarsal amputation. And we had to send documentation of the, of the chart, you know, there, there's an option of actually sending in additional information. So we chose that option, uh, rather than being educated another option. So we did a deeper dive into the medical record to try and find what they thought was missing in order to satisfy their criterion. And then we found publications that said, you know, patients on dialysis are not normal in their total protein and albumins because of their protein restriction.

I don't know if that will work. We'll find out. So we had about a 15.7% error rate under 20%. We'll see what happens with our additional information. But it's obvious that as we went through this, it became more and more obvious that what you need to do is take their list, the novitas and meridian list of indications and what's required as documentation, make a checklist, and then number the probes and then number every page in your documentation and reference it directly. So if they're looking for evidence of an A1c, you need to say, see page 30.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Oh my.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Gosh. And it's highlighted.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
So is this what you spent your evenings doing? I mean, I don't see how you—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
—Can. Oh, it's been days. It's been days, days. Probably killed at least one forest because everything has to be copied over and over and over. Yeah.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Yeah, yeah.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
And each one with the documentation, the evidence, any kind of literature, et cetera, needs to be sent with everyone. But what we found was that it was most important that we started identifying where they should find that information in the chart and we would highlight it so that they wouldn't have to go through and read what in our thinking, uh, was appropriate medical documentation. But they were either missing it or not aware, or didn't know where to look because some of these charts had over a hundred, 150 pages per day. And so we established this checklist and basically said, look here, look here, look here, look here. Wow. And we'll see if the next clinic that they asked us for, uh, we have less of these issues because we started implementing. I mean, this is a learning curve.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Correct. A checklist you started implementing your checklist. Checklist.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Yeah. So I would definitely send it with a checklist, but I also would spend some time reading what your referring physicians are saying. Because for example, you know, we had a, a podiatrist who is, sends us a, he's a surgical podiatrist, sends us a lot of referrals. They're almost all osteo. They've already been treated for a long period of time, but because of the way their electronic medical record works, they came in with a Wagner two. And it has been not changed despite the fact that—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
—They've got osteomyelitis, which makes them a 3. Yeah, right. Yeah. Because there isn't a one-to-one correlation between the, the, uh, ICD 10 and Wagner. So if they tried to create that, it's gonna fail.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Right. So again, what they're sending because of the way the electronic medical record just pre-populates it. Yeah. You know, the description is obviously a Wagner three because they've had an MRI and they're on IV antibiotics, but the chart says it's a 2—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
And, you know, and—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
So that's, that's, that's another issue that we can't control because yeah, we see them after all of this documentation has already taken place.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
And I got a call just yesterday from a, a manager of a clinic and you know, our new E&M physician billing, one of the things that you address in the new e and m is whether the problem is getting better, worse, or staying the same. That correct. More or less is how it's worded. And, and so they are unchanged, I think is, you know, the way that Medicare had worded the thing. So as part of their e and m, they're saying things are unchanged because they're still actively doing hyperbarics and debridement and these other things. And what we had been told in the past was that if you said they were getting better or the problem was better, and then you did active treatments like cellular products or hyperbarics or name it, that the auditors would say, well, if they were getting better, why did you need all these things?

So they use unchanged as the way they describe it until the patient no longer needs advanced therapeutics and they say, yeah, they're really, really better. Well, the auditor said they should have stopped hyperbarics because they classified the problem as unchanged instead of improved, and that they didn't make enough, uh, discussion about the fact that the patient was improving in response to Hyperbarics. It's like, you can't win. If you say they're better, they don't need hyperbarics. If you say they're not better, then you can't do hyperbarics because they're not responding. Right. There's just no answer for that one. They, they can make it whatever they want.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
And, and the other problem is that when you have chronic osteo, the overlying ulcer is completely irrelevant. Yeah. Because you are treating the underlying bone infection and the parameters for improvement of the bone infection would be probably a seg rate or a CRP. I mean, it's not the size of the wound that is over the exposed bone, if there is even exposed bone. So again, I think we've sort of boxed ourselves in with what is, by all accounts was a good initial attempt at trying to get parameters established around these specific diagnoses. But for example, if you have a gangrenous toe, how do you measure that? Yeah.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Yeah, yeah.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
You, you can, the patient does not have a wound. Technically they have a partially mummified digit. You can't measure that. There is no length with depth. How do you do that? And—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Yet most people will struggle to put some kind of measurement in because they have to have a measurement. So maybe we do ourselves a disservice. Maybe we ought to put in the chart that it's unmeasurable. I mean, I've never thought through that, but I don't, I think it would be worse if we did that. 'Cause then they'll say that we don't meet the criteria. I just don't think there's a way to win on that.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
No, there isn't. And but I think that if we need to explore the different permutations of what is being asked of us, so for example, if it's a Wagner four moist wound, healing is inappropriate somewhere, we have to put that out there that what they're asking for is inappropriate.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
It's not medically appropriate. It's not—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Medically appropriate. Yeah. Um, I cannot supplement a patient with protein who's on dialysis. I, you know, I—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
You can't even give those patients vitamins sometimes. Right, right.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Yeah. So depending on the vitamin, there's so many. There's, and, and, and I think part of the problem is that in so much of the, uh, evidence-based research that we do, we exclude all of these patients, uh, you know, the ones with diabetes or with renal failure, et cetera.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Yeah, yeah, yeah. So they're not even part of the clinical trials. And of course, when, when they CMS, and I think it was 2000, made the decision to cover diabetic feet, we were looking at no wounds because they wouldn't do ischemic wounds. So like it was all going down and diabetic foot ulcers based on, on really sort of one clinical trial was how we saved anything. So I would be terrified to revisit that with, with CMS at this point. Or they might decide they don't, like, they don't think there's enough data and we lose the whole thing. I just, I don't—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
See a No, no. I, I, no, I agree with that. I just think that, um, outside of the hyperbarics and outside of diabetic foot ulcer patients, I think addressing how these patients are treated in the real world might be of interest. But anyway, more to fi more to follow. We'll let you know the next podcast. How we, whether we educated them or whether—

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Yeah, I'm sure we've got people popping their Prozac. The only other thing that I saw when I got audited, which was really weird, and maybe people need to be aware of it, is that they're auditing the number of segments per patient, not the number of treatments per patient. So the flag that I got, I had very few patients, honestly, that year 'cause my volume was down so much, but because all of my patients completed their anticipated course, even with a handful of patients, I treated their sessions, their segments per patient was higher than the average, even though they, you know, were getting what, 2025 treatments a piece. And, and so I sent them a letter and said, you understand, we don't, we don't count segments that way, like, you know, what that means is that anybody who's doing treatments that are five segments instead of four guaranteed, they're gonna end up raising a flag because it's too many segments per patient on average compared to the rest of the country. Like, that's just a guarantee that, that you're gonna get audited.

Which I guess raises the last question, which is, is there any way to avoid these audits?

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Retire?

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
I was afraid you were gonna say that.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
No, no. There is no, they're completely, it is out of your control. But the only thing that is in your control is how you respond. And I think that if you are sort of like a Boy scout, always be prepared, prepare ahead of time. That checklist should be part of the thing that you document when you do your initial evaluation. And also be prepared to spend some time sending all of that, because you never know when one of these is gonna hit. So you have to take them seriously and we'll find out if they ask. The other question we don't know, the answer is, for example, one patient that we quote unquote had rejected was one date of service out of 40. We don't know if we don't reverse that assessment.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
Well, they ask for all those treatments. Yeah. Right. Yeah. That's, or just—

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
That one day of service. Yeah. We don't know. And so we'll find out what, unfortunately the only way to find out is to go through this.

Caroline E. Fife, MD, FAAFP, CWS, FUHM:
And I think what people also need to hear is that you're, you're not getting audited because they really believe something bad has happened. They're just auditing everyone. Yes. There seems to be a way to escape it. So, you know, Brian, and I've been looking for, for people like you who would, um, be interviewed just to talk about their experience. And I think we're finally getting past the point where people feel like it must mean they were doing something wrong, that, you know, we all sort of need to learn from your experience. So I really am grateful for your candor where you say, this is what they said, this is what we did. This is where we're failing. Or they think we're failing just because it's the only way anybody else is gonna learn from it to try to survive better. Especially when some of these things are capricious.

You know, who knew you needed to write in your hyperbaric procedure? Note that you use a hard sided chamber. I mean, that's just not something that any of us would've anticipated. So thank you for being willing to talk about this. And I'm sure there are lots of folks who are gonna have questions and want to know more information and wanna know how it goes. But I guess the only, the last thing I would say is people will call me and say, well, I see 80 patients a day, or some, you know, some number of patients that just beggars the mind. And all I can think of is how could you possibly get the kind of documentation that would be needed with that kind of volume? I think people have very unrealistic expectations about how many patients they're gonna be able to see a day, given the burden of documentation that's gonna be applied. I just, I think everybody's gonna have to adjust their, their anticipations of patient volume down in order to deal with this demand.

Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM:
Absolutely.

Brian McCurdy:
Thank you both so much for sharing your thoughts and experience with the audience. And for more podcast episodes, be sure to check out todayswoundclinic.com, SoundCloud, or your favorite podcast platforms.